recovery

At last it’s over. You are free and safely home at Bridge Farm. The judge saw through Rob and gave you full custody of both boys. Your nasty husband won’t be allowed to see Henry at all and will only be able to spend limited time with Jack under Pat and Tony’s supervision.

The nation breathes a sigh of relief. We can return to wondering who will win the Flower and Produce Show.

But I’m still worried about you.

I’m worried because you can’t cut Rob out of your life completely. He’s Jack’s father, and he will no doubt be manipulative over access. And he’s still living in Ambridge. You have a divorce to face, with legal and financial settlements to get through. You have been very brave, but you are going to need to continue to be so for a long time. And that will be hard.

I’m worried that things may be rocky for a while with Henry. He’s only a little boy, and he is bound to have a reaction too. Despite ‘Daddy’ having been unduly strict and irascible, he was there when you were not able to be. Henry may resent you for disappearing while you were in prison: he won’t be able to understand why you couldn’t be at home with him. He may tell you he misses Rob, and you will have to work out what to say and do that will help him.

I’m also worried because you’ve experienced a series of terrible traumas – coercive control over two years, multiple rapes, the incident that led to the stabbing, imprisonment, loneliness and separation from Henry. Plus the fear of being convicted, having Jack taken away and never seeing Henry again. You are a very private person; the trial must have been excruciating, with everyone knowing your business. These things will have had an impact. And there is bound to be a reaction. You may find yourself feeling flat and exhausted. Or even sinking into despair. Please don’t pretend to be OK if you are not. Please talk to someone, maybe your Mum or Kirsty, however hard it feels to do so.

And I’m worried that the reasons Rob was able to manipulate you haven’t changed. You are a thoughtful, caring person. But you are also vulnerable. You’ve lost a brother and a previous partner, and now all this. Even if you don’t feel the immediate need for professional help, when you are ready it might be good to explore the things that have happened to you, the impact they have had and how you want to live your life in the future. If you need professional help to do this, it is nothing to feel ashamed of. In fact it is a courageous and unselfish thing to do. Again it won’t be easy. But it will be worth it.

I’m not a complete idiot, Helen. I am well aware that you are a fictional character. But you represent something very real to listeners. You have touched a nerve in all of us about narcissistic charmers like Rob who in subtle and not-so-subtle ways undermine and manipulate their partners, leaving them confused, diminished, even broken.

We Archers fans love how this story has been given time to breathe. No other soap could have done this. As there is no other soap that could allow your character to face the aftermath of the abuse slowly and gently, in real time.

Some people think The Archers is all about smug middle class farmers to whom nothing ever happens, with a few working class folk thrown in for a bit of comic relief. How wrong they are.

Thank you Helen and The Archers for showing us what it’s like to meet Mr Wrong. It is a lesson that we all needed to learn.

We do not progress through the stages in a linear fashion. Some may have to be repeated. If we are not careful, we can get stuck at any of the first four, and never fully achieve the final one, of acceptance.

Today, those of us who voted Remain are feeling some or all of the first four stages. Only a few have reached the fifth by now. Some never will.

We have a right to feel angry. The referendum was unnecessary. Some time ago, David Cameron made a promise to appease certain members of his own party. He probably never expected to have to keep it.

After the result, the only honourable thing he could do was resign. As he did so, he was trying hard to appear to have achieved acceptance. But the catch in his voice gave the game away.

And he may never achieve it. Political careers in high office almost always end in failure. But this is failure of a most awful kind. Perhaps we can be kinder if our current Prime Minister shows statesmanship over the coming weeks and begins to chart the way through unprecedented choppy waters.

The reason many voted Leave was not about immigration or perceived European bureaucracy. It was a protest vote against the greed of big business, the banking crisis which has affected poor and vulnerable people much more than those who caused it, and a political ruling class that seems dangerously out of touch.

Can we listen really carefully to those who feel this way? We need to heed their voices, as well as the cries of anguish from those who voted Remain. And listen to both groups above the triumphal clamour of the minority who believe we have “got our country back”.

It is going to be very hard. Once hatred has been unleashed, it is hard to put it back in its cage. The rise of far right politicians and alliances are real and present dangers.

The size of turnout demonstrates that when people feel their vote will count, they are more likely to use it. So maybe we have to rethink our position on our current electoral system that disenfranchises so many.

And perhaps those towards the centre or on the left politically, if indeed such definitions are even valid in this context, can stop fighting one another and think about what matters? And who our real enemies are?

In the early stages of grief, it is important not to make momentous decisions. Words or acts of anger, hatred and blame will not help us.

So let’s hold on. Let’s be kind, to ourselves and to others. We are beaten. But we are not broken.

I went to a conference in Nottingham yesterday to learn about a technique called Open Dialogue. I wanted to know more because of how it has revolutionised the care of people who are in crisis in parts of Finland and the US, reducing demand on mental hospitals and transforming lives.

I care deeply about mental health services, although I don’t run them any more. These days I campaign to make them better. I volunteer in suicide prevention. I chair the Time to Change mental health professionals project. And sometimes I need help from services myself.

I wish you could have been there too. Some massive pennies dropped, not just for me but for everyone who hadn’t already appreciated the possibilities. We learned that Open Dialogue is about being with people rather than doing something to them. And we realised that here was a way to mend things that previously seemed unfixable.

Let me explain.

There are some who say that the NHS is broken. And that mental health services are badly broken.

I’m not sure that broken is a helpful way to describe things. I prefer to think of them as badly wounded. And when someone is wounded, you take care of them.

I believe that people in highly influential positions do care about mental health. They are just unsure about what to to do, other than saying they care. They know that mental health services around the country are buckling under the strain of increasing demand. Referral rates have never been higher. And continue to climb. Services find it increasingly difficult to discharge people because there is nowhere for them to go. Staff are overwhelmed, and there is a growing recruitment and morale crisis.

Added to which, successive governments say one thing about the importance of mental health but allow the opposite to happen regarding funding. Despite the fine words and promises in the response to the Mental Health Taskforce report published in February, we heard just a few weeks ago from NHS Providers that mental health trusts are not seeing the promised investment and some are reporting funding cuts in 2016 – 2017. Parity of esteem? Actions speak louder than words.

How might Open Dialogue help?

Firstly, it isn’t simply a technique for listening really carefully to people who experience trauma and distress AND their families so that together they can work out their own solutions, with support. It is also an extremely respectful way for people to relate to one another, in teams, across teams, organisations, health care systems and society. Even the NHS.

Secondly, Open Dialogue is the antidote to what is sometimes called the biomedical model, when doctor knows best and patients are compliant. This works when there is a fairly simple problem and solution. For example, a broken leg. It doesn’t work for the vast majority of health conditions in which people need to become the expert themselves if they are to lead fulfilling lives. And it certainly doesn’t work in mental health. Mental health professionals know this. But we organise and regulate mental health services as though we were fixing broken minds instead of legs.

Open Dialogue builds on what some call the Recovery Model, based on hope and fulfilment rather than simply diagnosis and treatment. It provides a method to apply a recovery-based approach, involving the whole family and team. It is the antidote to outpatient clinics and ward rounds.

Thirdly, Open Dialogue provides the basis from which to challenge many of the perverse incentives and restrictive practices that have grown up in mental health care out of fear of incident, media criticism or what a regulator might say. Such as staff spending more time documenting care than in giving care. The absolute adherence to risk assessment even though successive independent investigations show it to have limited predictive value. And risk management, which taken to extremes means that those who might possibly pose a risk to themselves or others, are cared for in inhumane conditions with no privacy or dignity, no sheets, cutlery, shoelaces, phone chargers or indeed any other item that someone somewhere has said might pose a risk. And yet we know that ligatures and weapons can be fashioned from almost anything. And that people who are ill, frightened and alone can be driven to do increasingly desperate things. The greatest risk management tool available is compassionate, skilled attention. Open Dialogue offers high quantities of that.

Open Dialogue is being used in a growing number of services in the UK. A research bid has been submitted and passed the first round of scrutiny. If successful, it will explore human, clinical and cost effectiveness, as well as developing a model that is scalable and sensitive to local circumstances.

And to Corrine Hendy, who I first met at an NHS England event about putting patients first last year: Your journey from being locked in a mental hospital to becoming a skilled mental health professional, public speaker and highly effective advocate for Open Dialogue, is more inspirational than any you will hear on X-Factor. I want to repay the inspiration you have selflessly given.

I wrote a piece recently for HSJ about the importance of recovery in the upcoming Mental Health Taskforce report. And it got me thinking about what that much overused but, to me anyway, beloved word “Recovery” means. Here are my thoughts.

Some people think that recovery is about getting better and then doing everything possible to forget that you were ever once unwell. But that would be a complete waste of the experience.

Our minds are like our bodies. They never forget being hurt or ill. If we let them, they will incorporate the scars from our experiences and use them to make us stronger and better people.

Recovery is about celebrating everything that has happened to us as an essential part of who we are, even those things that we may prefer to forget. This knowledge will help us as we face challenges in the future.

There are no sudden or miracle cures for psychological ill health. Recovery is slow, often unsteady, and at times very painful. That is why we should celebrate those who have achieved it as much if not more than those who have borne and overcome physical illness.

Sometimes we must go backwards in order eventually to go forwards, for example during therapy when exploring painful memories or damaging patterns we find ourselves repeating. And as with physical wounds, we cannot truly heal if we try to bury bad feelings deep inside ourselves. They have ways of getting out and causing harm at unexpected moments.

The word Recovery has nicer connotations than Rehabilitation. But they mean essentially the same thing. Recovery does not mean that everything is the same as it once was. That would be impossible. Even the healthiest and luckiest people encounter loss and pain from time to time. Recovery means harnessing the lessons we can learn from life events, however terrible, and incorporating them to make ourselves wiser, kinder but also more vigilant of the triggers that cause us pain or are the warning signs that we need to take care.

Like many of you, I am reading the excellent but troubling report by the King’s Fund into the state of our mental health services. I thought Stephen Dalton, Chief Executive of the Mental Health Network of the NHS Confederation was sharp yet lyrical on BBC Radio 4 Today in his analysis of what patients and staff are facing, and in his condemnation of the government and NHS England for saying one thing but apparently doing exactly the opposite at the same time. And that made me think as well.

It seems to me that our mental health services will forever be in a state of recovery. We cannot forget the changes we have experienced, including many hard-won and stunningly positive ones, particularly in the last couple of decades. But we also must face up to the damage that is currently being caused by the ongoing service cuts, and the havoc wrought by ill-thought through initiatives to save money or confuse prevention and early intervention with specialist care. Imagine the uproar if excellent cancer services were to be cut because money was being invested in health promotion and cancer screening instead?

These cuts to mental health services are carried out through fear on behalf of providers who get ferociously criticised if they don’t accept the unpleasant medicine willingly, and ignorance rather than cruelty on behalf of commissioners who are cushioned from the direct impact of the risks faced by patients and staff. The story on the Today programme of a dangerously ill man taken by ambulance to a voluntary café as a place of safety, who then had to wait 3 days with his desperate family before a hospital place was found was not a one-off. This is the result of too many bed closures alongside near collapse of community services in many places. We must face up to what is happening and not pretend it is all OK, or we risk slipping back all too quickly to the horrors of the past.

So we must be vigilant, wise and compassionate about the state of our mental health system. For me, compassion doesn’t mean keeping quiet. It means speaking up with intelligence, evidence and passion for something that matters more to me and to those reading this than almost anything else.

Let’s get together and let’s keep making a noise. Mental health services are not some luxury item that we can do without when times are tough. They are the essential bedrock of our society. In tough times, we need to invest in them even more.

Being able to say this with courage, conviction and purpose is what recovery means to me.

Surely a self-confessed mental health campaigner like me ought to be pleased about all this increased profile? Actually I feel three things:

Frustration

I feel frustrated and very angry for my fellow patients and erstwhile colleagues because of the cuts in care, both statutory and voluntary, that have led to the only “safe” place for people who are very unwell being in hospital, and to every acute mental hospital bed being full. It is not only cruel for the patients, it is deeply counter-productive. The young woman with a personality disorder languishing in an acute ward in North London (whilst funders slowly cogitate whether she should get a more appropriate service) is deteriorating daily and her problems are becoming ever more intractable and corrosive. If she had cancer, people would be doing marathons and having cake sales to support her. As it is, millions of people like her are seen by society only for their deficits rather than the assets that may lie buried deeply but are undoubtedly there. Parity of esteem? We’re having a laugh.

Love and gratitude

I feel huge love and gratitude to brave people like Professor Green for dragging mental illness and the stigma of suicide kicking and screaming out of the shadows and into the sunshine. I was moved by so much in Suicide and Me , including the rawness and vulnerability of the rugby coach as he bared his psychological all about feelings of worthlessness and what he is learning to do to protect himself from suicidal thoughts.

Today, the day after the programme was shown, I have a regular Board meeting with Grassroots, the small but highly effective suicide prevention charity of which I am a trustee. I love my fellow trustees and the amazing people who work and volunteer for Grassroots. We know what Professor Green has discovered for himself: suicide thrives where there is secrecy and shame. One of my shameful secrets used to be all those times in my life when I faked physical illness because I couldn’t get out of bed for feeling so hopeless, helpless and full of self-hatred that I wanted to stop living. It’s still very hard to ask for help, but many times easier now that I’ve outed myself. Bringing these shameful secrets into the sunlight and talking about them is our greatest tool to keep ourselves safe and to live a full and beautiful life in recovery.

Responsibility

I listened to All in the Mind this morning on iPlayer as it clashed with Suicide and Me. I salute the wonderful Claudia Hammond for dedicating her first programme of this series to young people’s mental health. I’ve written before about my concern that there is a lalala-I’m-not-listening response to the considerable increase in demand for children and young people’s mental health services. The programme takes a forensic interest in trying to find the reasons for this rise. There are various theories, mainly societal and social, but no conclusive explanation that could be used to stem the demand.

For staff working in these services, there is great anxiety – that they will miss someone extremely vulnerable, that the treatment they are giving is not sufficient, that they are spreading care and themselves too thinly. The pressure can feel close to unbearable.

We should be indebted to those who speak up about the challenge of working in mental health these days, like those on All in the Mind and the staff and leaders at Barnet Enfield and Haringey Trust on Panorama. Their courage and compassion shine.

These programmes stir up triggering thoughts and feelings in those who are susceptible. Social media can be a great source of support, but only if you are open, which also increases vulnerability. Twitter and Facebook have been very active this week.

I’ve had many thoughts myself. And I’ve come to a decision. I have more to give. I’m going to look for new ways to continue to tackle the stigma that affects not only those of us who experience mental illness, but also the availability and capacity of services to be able to tackle problems early with effectiveness and kindness. Watch this space.

And in the meantime, here’s to everyone who does what they need to do to keep on keeping on.

Since coming out about my on-off relationship with depression, I’ve lost count of the number of people who’ve asked me stuff and told me things. Some have been extremely helpful, some not so much.

Here’s my handy guide on what not to say to someone like me:

Please don’t ask “So why do you think you get depressed?” If I knew that, I’d fix it. I’m trying to find out, but it’s a work in progress.

Please don’t say “Have you thought about exercise?” You bet I have. And now I’m in recovery, I’d love you to come for a walk or bike ride with me. And see if you can keep up.

Please don’t say things like “When I retire, I’m worried I might get depression like you did. How can I avoid it?” I don’t know! What I do know is that depression isn’t caused by one thing. If you’ve got to this stage in life without experiencing it, chances are you never will. But I can’t make any promises.

Please don’t say “When I get depressed, I always…. (insert favourite pastime/exercise/indulgence.)” Thanks for the information, but you haven’t had depression. Or you wouldn’t say that.

Please don’t say ” Do you think talking/writing about your depression might make it worse/bring it on?” No I don’t. Sure, exploring this stuff is painful. But psychological wounds are like physical ones. They won’t heal if you simply cover them up. They will fester. To heal properly, wounds need sunlight and oxygen. Being open is the antidote to the nasty old stigma which makes people who don’t experience mental illness feel embarrassed about it and people like me who do feel ashamed.

Please don’t say “I never thought of you as the sort of person to get depression. I always thought you were so strong.” Yes. And that’s part of the problem. If you read Tim Cantopher’s Depressive Illness: The Curse of the Strong, it will help to invert your thinking about depression. As it did mine.

If I’m not on medication, please don’t tell me that I should be taking it. If I am, please don’t pass judgement, or ask if I have thought about talking therapies instead. And please don’t call antidepressants “happy pills”. People with physical illnesses such as cancer or heart disease don’t need well-intentioned, uninformed amateurs to opine on their treatment. People with mental illnesses are the same. It is neither good nor bad to take medication. It is just sometimes an essential part of getting better or staying well.

Please don’t say “You seem too jolly/optimistic to get depression.” Again, do read Tim Cantopher. Depression is rarely a permanent state. For me, the stark contrast between how I feel when depressed and my state when well is close to unbearable.

Depression isn’t the same thing as sadness. In my case, it is a combination of self-loathing and emptiness. But we are all different. See my letter to you for further info. It includes the details of the book I mentioned above.

Having listed some Please Don’ts, here is a precis of what I have found, through experience, really helps.

Do please:

Hold my hand when I need it

Be patient

Listen carefully and don’t overreact

Resist judging

Encourage me to seek professional help if I seem to be going round in circles

Tell me you won’t allow me to let this thing define me

Avoid defining me by it yourself

At the same time, allow me to incorporate it into my life.

Like anyone who experiences any form of mental illness, be it lifelong or more fleeting, I am so much more than it. But it is also part of me. I am learning to accept this, as I hope you can too. Not for me, but for the 1:4 people who experience mental illness from time to time. Because this is the only way we will truly eradicate the stigma that so besets us.

In a previous life, I ran a mental health trust for 13 years. It was really hard, but it brought some influence to bear on something that matters very much, i.e. the experiences of 1:4 people, who, like me, are sometimes mentally ill.

In 2010, as Chair of the Mental Health Network, I shared a platform with Health Minister Paul Burstow, Paul Jenkins, then of Rethink, Sarah Brennan of Young Minds and others at the launch of the coalition government’s mental health strategy No Health Without Mental Health. In 2013, I met Norman Lamb (who took over the ministerial role in 2012) and a few other senior colleagues to discuss why it was that the strategy hadn’t completely worked, in our opinion. The shocking evidence of widespread disinvestment in mental health services was by then becoming clearer, rigorously uncovered by investigative journalists Shaun Lintern (HSJ), Andy McNicholl (Community Care) and Michael Buchanan (BBC). Who are heroes in my opinion.

In times of plenty, mental health services have received at least a small share of extra resources available. Professor Louis Appleby’s excellent National Service Framework was delivered from 1999 – 2009 through increased investment in crisis services, early intervention and assertive outreach teams. And it was strictly monitored. Commissioners and/or trusts who thought they knew better than the best evidence of what underpinned compassionate, effective care for people with serious mental illness were found out and given no option but to improve. The architecture that did this monitoring has since been dismantled. We are left with regulation, inspection, adverse incident reporting and stories in the media.

The pressure by local commissioners on providers to swallow the current disinvestment medicine is considerable. Mental health leaders who make a fuss are viewed as lacking loyalty to their local health system. Were the same cuts made to cancer or heart services, there would be national uproar.

This tells us something, which is that stigma towards the mentally ill is alive and kicking within the NHS.

A true story: the other day, I mentioned the wonderful Alison Millar’s Kids in Crisis programme to someone senior from NHS England. I could tell they were irritated to be reminded that very sick children are currently languishing in police cells or being shipped hundreds of miles around the country while desperate clinicians spend hours trying to find a bed. This person actually said that parents are prepared to travel all over the world looking for the best treatment for conditions such as cancer. So why should CAMHS be different? When I reminded them that this wasn’t about highly specialist care, just access to care anywhere, they blamed the failure on local services and moved on to share their insights with someone else.

So we have denial about the impact of disinvestment, as well stigma. And I realise that in my new freelance world, I have a different sort of influence.

Thanks to Paul Jenkins, now CE of the Tavistock and Portman Trust, for his blog this week on the paucity of investment in mental health research. Another example of how stigma is flourishing towards those least able to argue for resources. And to Andy McNicholl for his piece on the bed crisis in adult mental health services, mainly caused because people are being hospitalised when other services have closed, or there is nowhere safe for them to go when they are ready for discharge.

Regarding the NHS Five Year Forward View (5YFV) here’s my 6-point plan for making mental health more mainstream. With measurements. Because if you don’t measure, you can’t manage.

1. Suicide prevention

Make suicide prevention the business of every citizen of the UK. Stop blaming mental health trusts and their staff for failing to keep people alive. The responsibility is much broader than that. Locate suicide reduction planning with Health and Wellbeing Boards. Make it their number one priority, with proper support as well as sanctions for lack of progress.

2. Mental health within the NHS

Expect every provider and commissioner to make the care of people who happen to experience mental illness their explicit business. Start with primary care. Require every NHS employee, including reception staff and everyone who works in a commissioning organisation, to do a minimum 1/2 day training, with an annual update, delivered by experts by experience. Report on compliance via the annual NHS staff survey.

3. Integration

Require local systems to produce integrated commissioning plans for all primary and secondary services. Particularly crisis care; dementia; all major physical conditions such as heart disease, strokes, obesity, diabetes and cancer; neurological conditions such as MS and MND; and musculo-skeketal conditions including chronic pain. Draw on the RAID model for measurement. Allow organisational form to flower according to local need. But also require investment in integrated services through an annual reduction in organisational overheads, and increased investment in the third sector.

4. Public health

Reduce premature death rates in people with serious mental illnesses of up to 25 years by making mental health promotion core business for primary care and secondary health providers in the statutory and non-statutory sectors. Target supportive, evidence based obesity reduction, smoking cessation, substance misuse harm reduction and exercise programmes for people with diagnoses such as schizophrenia, bipolar disorder, PTSD and personality disorder. Set ambitious targets over the next 25 years and monitor hard against them to help turn around the life chances of some of the most marginalised people in society.

5. Making the business case

It is up to the NHS to articulate and prove the business case for a change of approach in welfare for people with long term conditions such as serious mental illnesses. Commission the best brains eg Professor Martin Knapp at LSE to put the evidence together. Which is that it is considerably more costly as well as more cruel to condemn people who experience mental illness to poor, insecure housing and limited, insecure income, and for them to appear frequently and often pointlessly within criminal justice services.

But these costs do not occur in one place. Creating exciting opportunities for engagement and volunteering such as The Dragon Cafe can help people move from being recipients to full participants. Placing employment specialists within mental health teams and incentivising pathways into work are also proven to be highly successful. The alternative, i.e. penalising those in need of help, is counter-productive. It forces people to have to make themselves appear less able, makes them reticent about coming off benefits for fear of never getting them back should they need them in the future, as well as being extremely detrimental to their long-term well-being.

6. Research and improvement

Shine a light on why so little is spent on mental health research, given the financial and life chance costs of mental illness. Do something serious ang longlasting to reverse this. And then measure the impact longditudinally. No-one says we’re spending too much on cancer research, do they? Use that as our benchmark.

AND listen to the eminent and brilliant Professor Don Berwick, who makes the point that inspection never improved any health system. We need to invest in improvement science, architecture and skills for the whole NHS, of which mental health is an intrinsic, integrated part. Calling something NHS Improvement doesn’t necessarily make it an improvement body, by the way. But it is a good start.

I’ve shared these thoughts with the fabulous Paul Farmer, CE of Mind, who is leading one of three national task forces set up to help deliver the NHS England 5YFV. The other two are on cancer and maternity care. I know he wants to do the best he can. But he needs your help.

If you are part of the mental health family, and I would argue that every human being should be, please join in. Let’s seriously increase our ambition for those of us who experience mental illness, and focus hard on a small number of really important things that will really change lives. And then let’s concentrate and not squabble amongst ourselves as we set about achieving them.